Medical Coding for Operative Reports

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Medical Coding for Operative Reports

To assign the correct medical codes for any surgical procedure, medical coders need to have access to the detailed operative (OP) report.

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For accurate medical record coding, it is crucial for medical billing and coding specialists to have access to the actual operative report, and not just a billing sheet where the physician selects the codes.

Operative notes play a key role in documentation, especially in general surgery medical billing. It is the full report of what the surgeon performed during the surgery. The report would include all details such as the pre-operative diagnosis, post-operative diagnosis, brief description of what procedures were performed, title of the procedure, who performed the surgery, details of assistants, co‐assistants, co‐surgeons and team, type of anesthesia, any complications noted or unexpected findings, patient position, approach, and amount of blood loss.

However there are chances that “procedures performed” indicates something that is not included in the body of the operative report. Certain developments may occur during the surgery, which should be documented. These include: 

More time and complication than expected, which should be coded with a modifier to indicate the extra work involved.



Unable to perform the planned procedure



Unexpected findings upon entering the body that are worse than what test results showed before surgery.

Therefore, it is recommended that medical billing and coding specialists code from the postoperative diagnosis. Pre-operative diagnosis is not necessarily the reason for all the procedures the physician performs during a visit. Professional medical billing companies use codes based on the specific details given by the physician. For instance, while coding breast

surgery

procedures,

remember

that

sentinel

nodes

are

always

deep.

For

documentation, check how deep the physician dissected. For biopsied superficial lymph nodes, use CPT code – 

38500 (biopsy or excision of lymph node[s]; open superficial) or



38505 (biopsy or excision of lymph node[s]; by needle superficial)

Certain Tips When Coding from an Operative Report 

Review demographic details to ensure the physician is referring to the correct patient

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

Use a copy of the report and review it prior to assigning codes



Read the entire report for a clear idea about the surgery, not just the title



Highlight any unknown terminology and research it



Identify all actions



Look up for appropriate codes



Adhere to standard coding rules



Use modifiers as needed

You can also query the physician for the details that are not documented. If the report does not contain details that are mentioned in the title, then the physician must correct the documentation before it can be reported.

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Phone: 1-800-670-2809